Inside the California Teachers Study: The Future

March 8, 2017
| by Stephanie Smith

“Eating Burnt Toast ‘May’ Cause Cancer.” That was the big “talker” in newspapers and online this past January.

Almost immediately came the backlash in an article posted on The Telegraph website: “The government has been accused of ‘massively overreacting’ by telling people not to eat crispy roast potatoes or browned toast despite there being no scientific proof of a link to cancer.”

An ingredient in Nutella recently came under scrutiny as associated with cancer.

The week before, the spotlight had been on the popular hazelnut spread, Nutella, and a suggestion about problems with one of its ingredients.

As with burnt toast, there was controversy and confusion surrounding the study.

Stories like these are part of a relentless digital stream of information about cancer risk and prevention — at times involving stretched truths, at others outright contradictions.

“When I think of single items like burnt toast or even charred meat, almost always there’s an underlying foundation of biologic plausibility — we know that charring those proteins, in the laboratory, does bad things to cells,” said James Lacey Jr., Ph.D., director of the Division of Cancer Etiology at City of Hope.

“But for most of us, the amount of those things we consume is really ‘notes in the margin’ and it’d be hard for those things alone to cause cancer.”

Part of the issue, according to Lacey, is the studies behind these stories are nuanced, making it difficult to come away from them with satisfying — definitive — answers. By the time they reach the media outlets that circulate them, messages can become muddled.

“Over the years, such studies have come up with a mind-numbing array of potential disease-causing agents, from hair dyes (lymphomas, myelomas and leukemia) to coffee (pancreatic cancer and heart disease) to oral contraceptives and other hormone treatments (every disorder known to woman),” wrote Taubes.

“The pendulum swings back and forth, subjecting the public to an ‘epidemic of anxiety.’”

Leslie Bernstein, Ph.D., a cancer researcher at City of Hope, understands this “epidemic” well. She authored a study years ago that found a slightly elevated risk of childhood leukemia in children who ate hot dogs.

“It’s one of those situations where, if you look at a hundred foods, you’re bound to show a slightly higher or slightly lower risk of something,” said Bernstein, professor of the Division of Biomarkers of Early Detection and Prevention at City of Hope.

“I remember my son, who is a pediatrician, calling me because parents were flooding him with this question about hot dogs,” she said. “He said, ‘Mom, what does it mean?’ And I said, ‘It means nothing.’”

Science may say it’s “nothing” but when interest in food or ingredients is stoked, especially in the health-conscious and hypervigilant, it is difficult to quell.

“It’s human nature for people to want to know, ‘How can I prevent this?’” said Kristen Savage, M.P.H., a study administrator at City of Hope. “As humans we want to see a correlation. We want to say, ‘Oh I read this report and I just won’t drink wine.’

“The problem is it’s not that simple. There are things we know can decrease your risk of certain diseases, but there’s not a silver bullet.”

James Lacey Jr., Ph.D.

“Nutrition is the area where this is probably the most salient,” said Lacey. “The proverbial, ‘This food item is good for you one week and then bad for you the next week. There are detailed statistical scientific reasons why epidemiology studies are more likely than other kinds of studies to generate those conflicting findings.”

Lacey believes he and his colleagues in epidemiology could do more to correct this confusion. One idea is having scientists frame the context and messaging of their studies.

“Studies are almost always written from a scientific standpoint and we rely on the media to interpret them,” said Lacey. “I don’t think it’s fair for us to put that task on them.”

Instead of simply publishing a paper, he suggests scientists provide additional information in lay terms. (This is happening with some journals now, he says, but he hopes more follow suit.) And he believes, when possible, studies should be replicated before being published as a way of preventing the confusion caused by contradictory findings.

Another idea— much loftier than those aimed at media outlets — is about personalizing prevention — creating computer-generated models allowing people to plug in facts about their lifestyle and, in return, get a tailored prevention plan.

It could cut out the media middleman.

For example: a person who exercises, eats right, but can’t kick her smoking addiction, and has a family history of cancer. She could input information about her lifestyle and history into a program and get customized advice about reducing her risk of cancer and other diseases.

The concept is a bit like 23andMe, the direct-to-consumer genetic mapping service. “It’s the equivalent of 23andMe for lifestyle factors and family history and genetics all put together,” said Lacey.

The big question is how to start building a system that takes into account the nuance and complexity so difficult to pin down in studies, and packing them into a computer program.

The public is unaware about things that can increase cancer risk, like obesity and alcohol.

It is a complicated question, but Lacey believes the beginning of an answer lies with something at his fingertips: data from the California Teachers Study, a 133,000-member cohort that he runs.

Lacey hopes to pool data from the Teachers Study with that of other large cohorts to create something called a “Risk Assessment Tool.”

He uses burnt toast to explain the concept: “If toast is so bad for you, and someone had one slice of burnt toast today, how much quantifiably would that increase their risk of cancer if they also smoked and had a family history and were overweight?

“Those are the questions we should be able to answer,” said Lacey.

It is part of an attitude and mantra that Lacey and his colleagues in the Department of Population Sciences at City of Hope call, “Meeting people where they are.” It is about injecting more realism into cancer prevention — making it less about perfect adherence to rules about what to eat, what not to eat — what to do and not do — and more about carving a plan out of honest self-assessment.

“We don’t have to prevent the entire disease to enable someone to live a good, healthy life, right?” said Lacey. “We could say, ‘For a 40-year-old these are things that can help a person keep their bones strong, keep the weight off and reduce the risk of cancer.

“Oh and by the way, reduce their risk of heart disease and stroke and diabetes.'”

“We know that health outcomes vary by so many different factors and we know that the lived individual experience is so personal,” said Savage. “The ability to pool all that information and know what that person can do about a certain disease — that’s very exciting. We’re not there yet, but it’s exciting.”

Lacey, who has carved out a role with the Teachers Study as a technology-driven disruptor, sees personalized prevention as entirely possible — and on the horizon.

“The numbers are there,” said Lacey. “I think we just have to start asking the right questions and then churn through the data to get to the answers.”

**Research reported in this piece was supported by National Cancer Institute of the National Institutes of Health under award number R01-CA077398, UM1-CA164917 and U01-CA199277. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Stories of Hope is a monthly series that explores important issues in health care. This series is an inside look at the beginning, and future, of the California Teachers Study. Click to read Part 1 , Part 2, Part 3 and Part 4.

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